This week’s case study talks about a woman Susan who decided to have an abortion. Susan met her husband when they both just graduated from law school. She and her husband Rick wanted a large family and thus they have four children. When the couple’s youngest child was old enough to go to school Susan decided that she would like to return to legal practice. She realized how much she missed what she used to do before she became a mother and felt as if she had given up on her career. After she talked to her husband about the child care situation, Susan began her job application process as a legal assistant at a law office. While searching for a job Susan became pregnant and later on found out that the fetus has Down syndrome. The doctor was unable to tell Susan whether the Down syndrome will be mild or severe and knowing that having a child with a disability may prevent her from ever returning to the working world she decided to an abortion without her husband’s knowledge.

I’ll be looking at this case from a care ethics point of view. Care ethics’ main focus is the care of the patient, understanding that individual/person as an interdependent being, meaning that we need others for emotional and physical support. Unlike deontology and utilitarianism, care ethicists make their moral decision based on objective consideration instead of making these moral decisions objectively and impartially. It also created from the closeness of relationships, particularly trust. So for a care ethicist to figure out what is morally right or wrong in a situation the first thing they so is to identify the relationship involved, see if it is a health relationship and finally find what obligations they produce. For an individual to carry out this act he/she must be willing to put another person before him/herself.

Care ethics deals with a patient’s need and a doctor being able to fulfill those needs. In this case Susan felt that having an abortion would be the best approach and her doctor should respect her decision. Her doctor should be there to guide Susan and also help her through this tough decision. Susan puts her trust in her doctor that whatever decision she makes her doctor will respect it and show empathy towards her. Susan needed someone to understand what she’s going through and to be there for her. Trust is a great factor, in the situation Susan has a greater trust with her doctor than with her husband, and she may feel that if she told her husband that she wanted an abortion he would talk her out of it because his dream is to have a large family. But in terms of Care ethics regarding the fetus, shouldn’t Susan put the baby’s needs before her own needs? Yes her fetus has a disability but she can still care for her child and she could still have a career, her bay will be dependent on her, but what baby isn’t dependent. Susan’s child still can have a normal life, e.g. look at Becky in the TV show “Glee” she has Down syndrome but she also has a career. Susan will never know what her fetus would have become in the future.

Do you think that Susan should have told her husband about her decision to have an abortion?

It is difficult to say whether Susan’s decision is moral or not. This is because of the way an abortion is being used. This non-traditional manner makes one question all of the conditions surrounding the case when deciding the morality of her decision. The facts of the case are this; Susan has put her life on hold to have a family, she is the primary care taker of a very large family, she wants to return to her fulfilling life in the legal system, she then finds out that she is pregnant with a fetus that has Down syndrome, and she decides to have an abortion.

In Kantian deontology we must consider who is being affected by the decision because the categorical imperative must be met in order for this act to be considered morally correct. The categorical imperative here relies on what Susan is using as a way to get to her final goal of returning to her legal career. It gets tricky because normally, Kantian theorist would say it is morally wrong to have another human suffer to fulfill your own needs, but in the case of abortion the line between personhood and not is a blurred lined between theorists. In my eyes I agree with Thomson, that a clump of cells, not able to feel pain, should not be considered a human and therefore Susan is acting morally in relation to the fetus. Deontologists do not consider the uncertainty of the future when deciding what is moral or not and since we have considered the fetus non-human than the future of the handicapped fetus is not taken into consideration.

However, it is unclear if the husband knew about the genetic testing or the pregnancy in general. I am however sure that the husband would not be considered in methods to care for the child. So although Susan is denying her husband the right to another child, another offspring to carry on his genetics (the goal of reproduction), it seems that the emotional experience with the child would not be felt if the child was born or not. That is why I think the Rossian deontologist would agree that the prima facie duty in this case is duty to oneself, not duty as a wife or as a pregnant woman. The prima facie duty takes in consideration all of the conditions of the case and would agree that for Susan to be happy and fulfilled she had to go through with the abortion.

It may seem cruel but the most important aspect is for Susan to retain her autonomy, and her civil right to govern her body as she may. Susan reminds me of Hornstra, and how she put her career before having a baby. I think Hornstra and Susan would agree that their bodies and their futures would come before a clump of cells.

Some questions to consider:

Utilitarian’s take into account the uncertainty of the future, but what would bring the greatest suffering for the future, Susan’s unhappiness? A handicapped life of the child? A familial rift between a husband and wife?

Which is more important fulfilling your duty to the community or to nature (mother hood)?

Would you consider abortion active euthanasia? And if so, who would you consider responsible for the abortion, the mother or the physician performing the act?

In this case there are several different factors that contribute to the decision to have an abortion. First you have the four children that already exist. Then there is the desire of the mother to return to work which she chose to give up to care for her children. Finally the discovery that the fetus has Down’s Syndrome.

There are also several factors that may discourage Susan from getting an abortion. The desire both partners had to have a large family, which four children may or may not be. It may also be assumed that they are in a financial situation to care for another child. Also their youngest is in preschool so for at least part of the day the mother will have the time to devote to a new infant.

The moral question to be considered is, do these factors balance out in such a way to justify Susan obtaining an abortion?

Act utilitarianism says that a person should act in such a way to produce the greatest balance of good over evil. For this case not having the baby could be considered good for several reasons. One possibility is not bringing a baby home when there are already four children who require time and attention. Bringing a new child into a home can be very traumatic to other children. Another reason this may be considered a good act is that it gives the mother a chance to improve herself and increase her happiness. Her increased happiness would most likely affect her whole family positively as well. Going back to work would also affect her family positively financially. It does not say they need the money but her extra income could help them have opportunities they may not have otherwise. Because she had genetic testing on the fetus it is more than likely she is 35 or older, which means she may not be as young and able to run around after another young child besides that child also being disabled.

Negative effects of the abortion could include disappointment from her husband. He wanted a large family and even though she felt they were done he may have wanted to continue. If he feels very strongly about it, it could lead to anger, resentment, and divorce all of which would be very harm for the other children. It could also lead to guilt on the part of the mother alter on, especially if she does choose to have more children later.

I’m sure there are many other reasons for each side but I believe the balance of most good is on the side of obtaining the abortion. Are there any more valid reasons that could tip the balance? How would this situation change if the child would be normal? Would it be justifiable by any ethical principle to obtain an abortion if the fetus was normal and all other factors stayed the same?

Defined by the ethical implications of the concept “majority rules,” utilitarianism offers a form of justice that stands for the “actions that maximizes the overall good” of any situation. In this case we are presented with a 25 year old lady who is said to be suffering from a condition called Crohns diseases. The effects of this illness, as a result of her bad eating and lifestyle habits, have landed her in the hospital where she is informed of another devastating news. It appears that Maddy also has kidney stones and that is what is responsible for her abdominal pain. Aware of her options, Maddy is now faced with a decision that could result in a drastic change in her life. Does she adhere to the doctor’s advice or does she follow her own?

A utilitarian reading this case study would rather she follow the latter (in following her own judgment)! Should she decide to fulfill the latter in going forth with her own judgment, Mandy would surely be relieving herself as well as the healthcare system of any “burden.”Because she is medically uninsured, Maddy would have had to pay for all medical expenses including the medical surgical procedure herself. As you can see, this is trouble for someone who is seriously ill and currently earning very little. Proposing to not go through with the surgery procedure from a utilitarian point of view would, therefore, prevent this dilemma and would even save her from the excess stress (stress that can only worsen her current condition). Condoning this act will also benefit the health care system in the sense that it wouldn’t be forced to cover the expenses that Maddy fails to pay. In the end this works out for the greatest good in the sense of having satisfied both parties. The health system would be protected from the burdens of “payment” while Maddy, in addition to this, would also be spared a stressful lifestyle following the surgery (the stress would come from trying to figure out the payment situation).

Some may argue that Maddy’s need for surgery outweighs the effects of the cost on her life or the health care system but a utilitarian may argue the opposite. Stress, indirectly, played a major role in the “worsening” of Maddy’s condition when she had to juggle between a job and school. If she decides to go through with the surgery, Maddy stands the possibility of being “stressed out” again and that can cause her to be in a state that is far worse than where she currently is right now.

At this point, the only sound resolution would be to get an insurance. She should speak to her physician or someone else that she trusts about finding an insurance policy that is just right for her. OR she can work out some kind of arrangement with her physician; say… to pay of the medical bills in small increments every week or month until it is all paid off although, I’m not so sure how that would work out or if it’s even possible at all. However, proceeding to follow one of the three suggested options about Maddy’s condition will be sure to grant her the best possible care, in the eyes of utilitarian laws.

What other alternatives from you assigned prospective can you provide for Maddy in this case?

Maddy is a smart, hardworking girl. She has not been given a lot of help with her schooling and has had to struggle on her own. On top of all that she must deal with the side effects and expenses of Crohns disease, a chronic inflammatory disease of the gastrointestinal tract. Due to her disease, Maddy must be careful not to overwork or overstress herself as it may induce flare ups. This is hard to do considering she must work while going to school and must worry about being able to pay all of her bills. After being malnourished and dehydrated, Maddy has suffered from two infection-causing kidney stones because she has not been able to pay for her Crohns medication. She refuses the required surgery because she does not have health insurance and she cannot pay out of pocket.

The health care system is not what it should be, but there are politicians and activists trying to correct that. Maddy deserves to have health care and she deserves to have the treatment that would allow her to continue school and continue to work. Now some, such as a utilitarian, may disagree with this view. The utilitarian may say that Maddy should not receive health care because that would be taking it away from another person who has a more serious condition. It is true Maddy’s condition is not life-threatening, however, that would mean that Maddy is being used as a means to an end. This idea goes against the very nature of deontology.

If the doctors wanted to help Maddy by doing the work pro bono, Kantian deontology would see that as the best decision because that would mean that the doctors are performing a duty out of good will. They are following the moral law by treating Maddy. Another approach would be to appeal to a health care committee to see if Maddy could receive health care based on their personal and professional recommendation. Rossian deontology would have a similar approach to this situation. Ross would argue that the physicians have a “prima facia” duty to help Maddy, either by doing the work pro bono or by giving her a large discount on the procedure.

There are a few duties that Ross states that would apply here: duty of beneficence – the duty to help others, duty of non-malficence – a duty to avoid harm to other people, and a duty of justice – a duty to make sure people get what they deserve. Anyone of these duties can take precedence over the other but all would agree that Maddy deserves treatment without the stress of paying for the costly procedure. The doctors have a duty of beneficence to help Maddy. They have a duty of non-malficence to prevent Maddy’s condition from getting worse. The large sector of health care cannot look at each case and decide who really deserves free medical care or not. If it did then I’m sure this controversy of our health care program would be alleviated much quicker. Maddy is someone who deserves medical care. She is a hardworking student that pays her own bills and is diagnosed with a serious and costly disease but for whatever reason she has not been provided with health care. Therefore, it is the doctor’s duty of justice to make sure she is treated, either by doing the work pro bono, giving her a large discount on the procedure or by appealing to some sort of health care committee to see that Maddy gets the health care she deserves.

Emma Ogden has been suffering from a persistent heart defect her whole twelve-year-old life. Dr. Abdul Hamid conveys to her and her parents that the only chance of survival that Emma has is a risky heart transplant procedure. Emma, who is mature for her age, decides that she does not want to go through with the procedure and accept the consequences which would be death. Dr. Hamid is startled and wants to treat her but is stuck.

In deontology, morality is based on what one's duty is and doing one's duty. In this case, the duty of the physician is to go through whatever channel he can and see to it that the heart transplant takes place. Dr. Hamid must overlook the fact that Emma has stated that she does not want the heart transplant; after all, Emma is still a minor. How can a twelve-year-old know what's best for her in a field that makes their students study for practically twelve years. Dr. Hamid does have a duty towards the parents of Emma since she is a minor. He needs to talk to Emma's parents and get the consent to go through with the procedure. According to deontology, I feel that Dr. Hamid's duty towards Emma's parents is less important than his duty as a physician. If consent cannot be obtained, Dr. Hamid's duty still doesn't change in performing the operation. He must then, like the last sentence of the case study says, obtain a court order giving him permission to operate against the wishes of both the girl and her parents.

In Kantian deontology, we have what is called perfect duties. Essentially, a perfect duty is one that does not go against natural. Of the numerous perfect duties, there are three that stand out: do not kill, do not lie, and the duty to keep promises. The third and final perfect duty that Kant believes is most relevant here. When Dr. Hamid became a physician, he took the Hippocratic Oath. In that Oath, he specifically pledged that he would "...apply, for the benefit of the sick, all measures that are required..." By finding a way to operate on Emma, Dr. Hamid would be upholding the truths that he pledged to years ago.

In Rossian deontology, we have what is called prima facie duties. Prima facies duties are different from Kant's perfect duties and imperfect duties in a sense that a perfect duty can be transgressed in order to obtain an imperfect duty or rather a greater good. Dr. Hamid's prima facie duty is to go against the family's wishes in order to obtain permission a court order giving him permission to perform the heart transplant. The greater good here is the heart transplant since it will give Emma the best chance of survival, and so, according to Rossian deontology, Dr. Hamid must see to it that it takes place.

The main conflict in this Case Study is whether or not Doctor Hamid should push for the heart transplant even though the 12 year old patient Emma, wants to forgo the procedure. The patient realizes that the procedure would not guarantee her full recovery stating that there is “10-20 percent chance at 5 year survival”. Emma has gone through so many previous procedures and much to her dismay still has complications with her heart. Emma also has already convinced her parents to follow her wishes although she condemns herself to death. In Emma’s eyes, passive euthanasia, or the denial of any further treatment to “let nature take its course” to a natural death is worth more to her rather than going through another intense procedure and the grueling path to recovery.

Taking the stance of Care Ethics, the doctor must consider the relationships at stake rather than trying to justify his actions through some sort of moral code or standard as most other ethical theories do. I believe that if the Doctor must show true empathy and compassion for other or his patient, Dr. Hamid must respect both Emma’s and her parent’s wishes. It is not hard to understand why Dr. Hamid was “taken aback” by Emma’s request to deny treatment, essentially because no health care professional wants to let their patient die. Dr. Hamid must relate to Emma’s situation and sympathize with the fact that she has undergone a myriad of treatments already and although some were successful, she still suffers from her heart condition. If Dr. Hamid wants to truly retain the relationship between Emma and her parents, as proponents of Care Ethics argue, then Dr. Hamid cannot request a court order for the procedure. Again, I realize that this goes against almost all beliefs as a doctor, and under any other ethical perspective this seems drastically immoral, under care ethics it is the relationships in certain situations which must be considered. Care Ethics also allows individuals to be interdependent on attaining their interests, and in this case Emma’s interests are to forgo the transplant and stop fighting the condition.

What other obvious ethical perspectives’ does this decision go against?

Do you think there is an alternative solution? (still maintaining a strong patient professional relationship)

This is a very interesting case. The issue at hand is whether or not Dr. Wilson should perform a hysterectomy on Carmen Diaz, in addition to the Diagnostic Laparoscopy which was the initial procedure. This issue arose when Dr. Wilson discovered, during the laparoscopy, that Carmen had several large tumors about her uterus. Although the tumors were benign, they tend to be painful, and were most likely to blame for the near crippling pain that Carmen experienced for the past three months. Upon signing a consent form for the diagnostic laparoscopy, Carmen granted Dr. Wilson the right "to do what is medically necessary and advisable if unexpected circumstances arise during the surgery." The question is whether this hysterectomy, which will consist of removal of Carmen's uterus, is medically necessary.

Taking stance on the ethics of care, I feel as if it is necessary for Dr. Wilson to perform the hysterectomy. Care ethics, as the name implies, focuses on caring for others, by showing empathy for them as well as showing concern for their needs and interests. Rather than putting emphasis on universal moral standards, as do ethical theories of consequentialism and deontology, care ethics places an emphasis on the importance of relationships, and the responsibilities that arise out of such.

When Carmen signed the consent form and gave Dr. Wilson the right to do whatever was medically necessary, she (Carmen) made way for their relationship to take form of the friendship model. The friendship model is right in tune with care ethics, contending that in a medical setting, the physician assumes the interests of the patient, while the patient puts his/her trust in the physician. In this situation, Dr. Wilson would be assuming the interests of Carmen since Carmen trusted her so much as to give her such significant rights. With the knowledge that Carmen has large tumors that are painful, Dr. Wilson would be acting in the best interest of Carmen by performing the hysterectomy and removing the tumors. This would rid Carmen of a terrible pain that has restricted her physical activity and worsened the quality of her life. Dr. Wilson would also be acting in the best interest of Carmen by performing the surgery now, and not allowing Dr. Wang to awaken Carmen and plan the hysterectomy for a future date. If the surgery is put off, Carmen would still have to deal with the crippling pelvic pain until her rescheduled surgery. Dr Wilson would also be acting in the best interest of Carmen in terms of Carmen's psychological health. If the surgery is put off until a later date, Carmen has to carry two burdens; the burden of pain that the tumors are causing her, and the burden of fear and anxiety that she would soon have to undergo a serious surgical procedure, and she would soon have her uterus removed.

In assessing Carmen's needs, I believe we can all agree that Carmen needs for her pain to cease as soon as possible. The terrible pain she experienced impaired her ability to work and to do routine daily chores, thus making life that much more difficult. Since the ethics of care are normative, Dr. Wilson is able to assess those needs and determine whether or not she is taking the right action. However, it does seem tough to try and balance the right and wrong of this procedure; is it right to rid Carmen of her pain, or is it wrong to perform a procedure as drastic as removing a uterus without notifying Carmen first?

Care ethics hints at a gender difference in reasoning. Thanks to Carol Gilligan, it is understood that females are more inclined to protect the interests of everyone involved, whereas men are more inclined to sacrifice one's interests. It can be argued that while Dr. Wilson was trying to protect Carmen's interests by performing the hysterectomy, Dr. Wang (who is a male) was sacrificing Carmen's interests by planning to awaken her and delay the hysterectomy. What are your opinions on that matter?

Another interesting question is whether empathy is a competent approach to determining right and wrong actions in the medical field. Empathy consists of attempting to recognize one's feelings and trying to share in those feelings, without actually being in the same situation. In this case, Dr. Wilson couldn't be aware of Carmen's feelings because Carmen was anesthetized. Could Dr. Wilson adequately share in Carmen's feelings of learning that she no longer has a uterus and therefore no longer has a functioning reproductive system? Surely Dr. Wilson doesn't know the pain of waking up to the news that you won't be able to reproduce. If Dr. Wilson were to perform the surgery, what do you expect Carmen's reaction to be? Will she be happy that the pain is gone, or sad that she can't have children, or both? Will she understand that Dr. Wilson was acting in her best interest?

The major conflict in this case revolves around whether or not it would be proper and ethical for Dr. Wilson to perform a laparoscopic hysterectomy on Carmen, after it was discovered through a diagnostic procedure that she had several benign, but painful uterine tumors. Although Carmen signed a consent form that gave Dr. Wilson the rights to do what is “medically necessary and advisable”—the anesthesiologist, Dr. Wang has doubts about whether Carmen has given proper consent for the hysterectomy and if it is in fact medically indicated.

As a quick recap, utilitarianism seeks to create the “greatest possible good (or happiness) for the most amount of people.” Happiness or the “maximization of utility” is primarily defined in two different ways: Bentham believed it to be pleasure and the absence of pain, Another way to analyze utilitarianism, is to understand how closely it is tied to the idea of “opportunity cost,” a concept developed by Jon Stewart Mill which refers to the value of whatever one had to give up in order to pursue another course of action. Typically, a utilitarian will want to pursue the course of action with the lowest opportunity cost, thus making the most efficient use of resources.

Under utilitarianism, it seems that Dr. Wilson’s intention to perform the laparoscopic hysterectomy would not only be the reasonable course of action, but the preferable one as well. In terms of resources, Dr. Wilson conserves both time and energy by performing the laparoscopic hysterectomy while she already has Carmen in surgery and anesthetized. I believe doing the hysterectomy during the laparoscopy is the option that has the lowest opportunity cost. By getting rid of the ailment in this one procedure, Dr. Wilson allows both her and Dr. Wang to have a greater amount of time in the future to help other patients that need care, since the will not have to put the surgery off for another appointment. Utilitarianism is concerned with the “good of everyone,” thus only having one procedure will benefit those in need of medical care (which Carmen’s second procedure might have prevented). Additionally, there is a certain amount of risk for a patient each time they go under anesthesia, by consolidating the diagnostic and treatment surgery, this risk is compounded. According to Bentham, pleasure is defined as an absence of pain, by only having one immediate surgery, Dr. Wilson is preventing Carmen from experiencing the pelvic pain that has so limited her daily life for the past few months. Also, by only having one surgical procedure—Carmen is saved the pain of a second procedure. Because Carmen will have had the procedure already completed, she will be able to return to work sooner and not have to miss yet another day to treat the tumors. Dr. Wilson's decision to perform the laparoscopic hysterectomy makes the best use of medical resources and prevents Carmen from experiencing any more of the pain that had severely impacted her daily life, and thus would likely be supported by the utilitarian perspective.

Utilitarianism is a form of consequentialism, and as a consequence of this surgery, Carmen will most likely be relieved of the pain that has been so heavily impacting her life—the main goal of her. The other consequences are hard to determine and require a fair amount of speculation; I find this to be a weakness of the utilitarian perspective and it was hard to determine specific consequences for certain without more information. For example, what if Carmen, upon being informed of the hysterectomy, becomes deeply depressed at the idea that she will be unable to have children and though physically well, is unable to continue. Despite the infinite variety of consequences, I still believe that under utilitarianism, Dr. Wilson's intention to perform the hysterectomy is the best course of action and the utility is maximized to a degree where it seems to outweigh the possible negative consequences.

How do the goals of utilitarianism in this example compare with the ethical perspective that you are looking at? Even if the goals are different- did anyone come to a similar conclusion?

Utilitarian perspective aside, this case is something I struggled with. Personally, I found it hard to put my feelings aside in order to argue the utilitarian perspective. From a patient perspective, I just can’t help but to think how I would feel emotionally, waking up from a surgery that was supposed to be diagnostic to find that my uterus had been removed. Here are some questions that I started to think about while I was analyzing the case study that I think would be very interesting to explore.

How does the solution offered by the utilitarian perspective compare to the “restoration of autonomy” that Ackerman argues is the goal of medicine? Are there any perspectives that you feel offer a better solution?

Though Carmen’s physical problems have been solved, how would the solution offered by the utilitarian perspective impact her personal identity?

After Carmen was told that it would be a diagnostic procedure, was Dr. Wilson overstepping her bounds and deceiving Carmen in wanting to perform the hysterectomy—or was she just doing what she thought was “medically advisable and necessary?” What implications might this have for Dr. Wilsons future relationship with Carmen?

If you could, using the different patient-professional models we read about this week, how would you revise either Dr. Wang's or Dr. Wilsons' approach? Would this revision change the outcome according to your philosophical perspective?